What's on this Page
6 Interesting Facts of Hallux Valgus
- Hallux valgus is a common progressive forefoot deformity consisting of lateral deviation of the hallux (big toe) at the metatarsophalangeal joint accompanied by medial deviation of the first metatarsal (metatarsus primus varus)
- Great toe angulates away from midline and toward other toes
- Bony eminence at medial aspect of first metatarsal head is referred to as a bunion
- Heredity and constricting footwear are considered major contributing factors
- Deformity may be asymptomatic or result in foot pain and dysfunction
- Pain typically located over bunion or beneath the lesser metatarsophalangeal joints
- Diagnosis is based on clinical history, physical examination, and radiographs
- Radiographs assist in deformity assessment and treatment planning
- Treatment consists of conservative and surgical measures
- Conservative treatment is the preferable first option and may improve symptoms and function, but it does not correct the deformity
- Many surgical procedure options are available; success depends on choosing best technique for a given deformity
- After appropriate surgical intervention, most patients are satisfied and have good clinical result
- Hallux valgus is a common progressive forefoot deformity consisting of lateral deviation of the hallux (big toe) at the metatarsophalangeal joint accompanied by medial deviation of the first metatarsal (metatarsus primus varus)
- Great toe angulates away from midline toward other toes
- With progression, the first metatarsal head slides medially off the sesamoids
- Bony eminence at the medial aspect of the first metatarsal head is referred to as a bunion
- Thickening or inflammation of the bursa overlying the first metatarsal head can accentuate this medial eminence
- Bony eminence at the medial aspect of the first metatarsal head is referred to as a bunion
Clinical Presentation
History
- Clinical history of Hallux Valgus includes duration of symptoms, activity modification, usual footwear choices, previous interventions, history of foot trauma or arch collapse, and familial inheritance
- Pain may be present
- Patients may complain of great toe “pointing inward” (ie, laterally) toward other toes and causing:
- Difficulty fitting desired footwear owing to deformity
- Cosmetic concerns
- Symptoms can include:
- Pain
- First metatarsophalangeal joint pain, soreness, or stiffness
- Inflammation of overlying bursa can cause pain over medial eminence
- Pain may be located beneath the lesser metatarsophalangeal joints
- Malfunction of a given metatarsophalangeal joint may produce pain at another metatarsophalangeal joint
- Pain/pressure under second or third metatarsals can result from transfer metatarsalgia (pain at different ray than mechanically impaired ray)
- Typically worse when wearing tight shoes or high heels and with weight bearing
- First metatarsophalangeal joint pain, soreness, or stiffness
- Burning or numbness owing to compression of digital nerve
- Pain
- Patients may complain of great toe “pointing inward” (ie, laterally) toward other toes and causing:
Physical examination
- Both bare feet examined in sitting and standing positions
- Observation
- Gait may be antalgic or externally rotated
- Alignment
- Medial deviation of first metatarsal and lateral deviation of hallux
- Pronation of hallux (nail faces medially)
- Inflammation and edema over medial eminence; ulceration may be noted
- Forefoot may be wide
- Deformities of lesser toes, midfoot, or hindfoot
- Pressure of the great toe against the second toe may lead to malalignment, subluxation, or dislocation of the second metatarsophalangeal joint
- Thickened skin over metatarsophalangeal joint and/or plantar surface (callus)
- Observation
- Palpation
- Focal tenderness to palpation over medial eminence
- Tenderness over dorsal hallux metatarsophalangeal joint may indicate arthritic component
- Tender plantar calluses indicate transfer lesions under the lesser metatarsophalangeal joints
- Owing to shift in load-bearing capacity from first ray (metatarsal, sesamoids, and hallux) across to lesser toes
- Focal tenderness to palpation over medial eminence
- Range of motion
- Decreased mobility of metatarsophalangeal joint
- Active and passive range of motion is assessed
- With neutral position as recorded 0°, average passive dorsiflexion is 67°, and plantar flexion is 20° in adults aged over 45 years
- Motion evaluated in reduced and nonreduced positions
- Manual attempt to reduce deformity is made while gently dorsiflexing and plantar flexing the first metatarsophalangeal joint; can determine degree of correction that may be achieved
- If motion is increased in reduced position, it may suggest contracture of lateral soft tissues
- If motion is decreased in reduced position, it may indicate a change in the articular surface angle
- If motion is restricted in reduced or nonreduced position, there may be degenerative change
- Pain or crepitus may indicate degenerative changes
- Manual attempt to reduce deformity is made while gently dorsiflexing and plantar flexing the first metatarsophalangeal joint; can determine degree of correction that may be achieved
- Toe pronation on extension can indicate intrinsic malalignment
- Active and passive range of motion is assessed
- Hypermobility of first ray
- Increased laxity of the first metatarsocuneiform joint may contribute to deformity
- Examination performed with ankle in neutral dorsiflexion
- Second metatarsal head is stabilized with 1 hand while first metatarsal head is moved dorsomedially then plantar-laterally to gauge degree of hypermobility; compared with contralateral side
- Grading may be described as mild, moderate, substantial mobility, and hypermobile
- Technique has consistent intrarater reliability, but little clinical objectivity comparing magnitudes among examiners
- The second metatarsophalangeal joint should also be examined
- Increased laxity of the first metatarsocuneiform joint may contribute to deformity
- Ankle, subtalar, and transverse tarsal joints
- Hindfoot deformity may contribute to development of forefoot issues
- Ankle joint: assessed by dorsiflexing and plantar flexing the foot at level of ankle joint
- Allows sagittal plane motion of 20° of dorsiflexion to 50° of plantar flexion along an axis running between tips of the malleoli; marked variability between individuals
- Subtalar joint: assessed by holding heel with palm of 1 hand, fingers on posterior heel; with other hand, the foot is inverted and everted
- Range of motion approximately 30° of inversion and 15° of eversion; magnitude variable between persons
- Transverse tarsal joint: evaluated by holding heel with palm of 1 hand, fingers on posterior heel; with other hand, the foot is abducted and adducted
- Normal motion is approximately 20° of adduction and 10° of abduction
- Ankle joint: assessed by dorsiflexing and plantar flexing the foot at level of ankle joint
- Hindfoot deformity may contribute to development of forefoot issues
- Decreased mobility of metatarsophalangeal joint
- Peripheral vascular perfusion and motor/sensory function are evaluated
- Vascular occlusive disease can preclude surgical options
- Numbness or paresthesia over the dorsomedial distal phalanx can result from compression/irritation to dorsal cutaneous nerve overlying the bursa
Causes
- Cause of hallux valgus is uncertain but likely multifactorial, including:
- Intrinsic factors
- Genetic variations that result in altered biomechanics
- Sex (more common in females than in males)
- Ligamentous laxity
- Other foot deformities (eg, pes planus, pronated hindfoot, metatarsus primus varus)
- Age (prevalence increases with age)
- Neuromuscular disorders (eg, cerebral palsy, stroke)
- Extrinsic factors
- Footwear (high heels, narrow toe box)
- High heels increase forefoot loading; may exacerbate deformity
- Excess weight bearing
- Footwear (high heels, narrow toe box)
- Intrinsic factors
- Progressive deformity involves several steps, in concert with predisposing factors; often a parallel process rather than sequential
- Begins with lateral deviation of great toe and medial deviation of first metatarsal
- Later stages involve progressive subluxation of the first metatarsophalangeal joint
- Bursa over joint thickens over time owing to pressure of footwear on medial eminence
What increases the risk of Hallux Valgus?
Age
- Prevalence increases with age
- Age of onset varies widely
Sex
- Affects women more commonly than men
- May be associated with more narrow, high-heeled footwear
Genetics
- Familial association
- 83% of patients have a positive family history of hallux valgus deformities
Other risk factors/associations
- Tends to be bilateral
- Other possible associations include:
- Long first metatarsal
- Oval or curved metatarsophalangeal joint articular surface
- Increased first ray mobility
- Achilles tendon tightness
- Pes planus
- Plantar gapping of first metatarsal cuneiform joint
How is Hallux Valgus diagnosed?
Primary diagnostic tools
- Diagnosis is by clinical history, physical examination, and radiography
- Obtain dorsoplantar and lateral weight-bearing radiographs for all patients with suspected hallux valgus
- Additional radiographic views may be necessary to assess deformity and assist in treatment planning, but advanced imaging is typically not necessary
Imaging
- Weight-bearing dorsoplantar and lateral radiographs of the feet
- 2 important angles are assessed to determine radiologic severity
- Hallux valgus angle
- Angle between long axes of proximal phalanx and first metatarsal
- Intermetatarsal angle:
- Angle between long axes of first and second metatarsals
- Hallux valgus angle
- Other angles that may be useful in treatment planning include:
- Distal metatarsal articular angle (10°-15°)
- Hallux interphalangeus angle (normal angle less than 10°)
- 2 important angles are assessed to determine radiologic severity
- Severity of hallux valgus can be classified based on standing anteroposterior radiographs
- Normal
- Hallux valgus angle: less than 15°
- Intermetatarsal angle: less than 9°
- Subluxation of lateral sesamoid on anteroposterior view: none
- Mild
- Hallux valgus angle: less than 20°
- Intermetatarsal angle: 11° or less
- Lateral sesamoid subluxation: less than 50%
- Moderate
- Hallux valgus angle: 20° to 40°
- Intermetatarsal angle: less than 16°
- Lateral sesamoid subluxation: 50% to 75%
- Severe
- Hallux valgus angle: greater than 40°
- Intermetatarsal angle: 16° or greater
- Lateral sesamoid subluxation: greater than 75%
- Normal
- Other radiographic observations that can be useful in guiding treatment include:
- Various other angular and positional relationships (eg, distal metatarsal articular angle, interphalangeus angle)
- Metatarsal head shape
- More convex articular surface is more prone to hallux valgus deformity
- Position of sesamoids relative to metatarsal head
- May demonstrate severity of deformity, degree of pronation, and pathologic changes in sesamoids
- Gapping of plantar aspect of first metatarsocuneiform joint
- Arthrosis of metatarsophalangeal joint
- Metatarsus adductus
- Presence of intermetatarsal facet or os intermetatarseum
- Additional radiographs can include nonstanding lateral oblique views and axial sesamoid views
- Axial sesamoid view may aid in determining extent of intrinsic malalignment
- Can be useful preoperatively
Differential Diagnosis
Most common
- Hallux rigidus
- Osteoarthritis of the first metatarsophalangeal joint
- As with hallux valgus, symptoms include pain, stiffness, and swelling at first metatarsophalangeal joint
- Differentiated by tender bump (bunion); if present, typically located on dorsal aspect of metatarsophalangeal joint
- Examination may show limited and painful range of motion, especially dorsiflexion; crepitus may be noted
- Diagnosis based on physical examination and radiographs (eg, sclerosis, subchondral cysts, joint space narrowing, osteophytes, dorsal bone spur)
- Gout
- Gout is a common inflammatory arthritis caused by deposition of monosodium urate crystals
- As with hallux valgus, symptoms include pain, stiffness, and swelling at first metatarsophalangeal joint
- Differentiated by relatively acute onset of pain, redness, and swelling in joint
- Diagnosis based on history, physical examination, and laboratory testing
- Definitive diagnosis by joint aspiration
- Diagnostic gold standard for gout is presence of negatively birefringent monosodium urate crystals in a synovial fluid sample viewed under polarized light microscopy
- Important to differentiate from septic joint
- Definitive diagnosis by joint aspiration
- Rheumatoid arthritis (Related: Rheumatoid Arthritis)
- An autoimmune disease; immune complexes within synovial membrane cause inflammatory response leading to synovial thickening and joint destruction
- Frequently affects joints of the feet; hallux valgus is predominant foot deformity
- Similar symptoms include pain, swelling, and stiffness; resulting deformities include bunions, claw toes, and metatarsalgia
- Affects multiple joints; typically both feet and similar joints involved (symmetrical)
- Diagnosis based on clinical criteria, laboratory results (eg, levels of rheumatoid factor, anticyclic citrullinated peptide; antinuclear antibody assays), and imaging features (eg, erosions, joint space narrowing)
- An autoimmune disease; immune complexes within synovial membrane cause inflammatory response leading to synovial thickening and joint destruction
- Septic arthritis
- Infection within joint space; typically bacterial
- Important to consider in patients with acute joint disease
- Can lead to rapid, irreversible joint destruction; associated with significant morbidity and potentially fatal
- Similarly, presents with joint pain, redness, and swelling
- Differentiated by relatively acute symptom onset; fever may be present
- Diagnosis suggested by clinical history, physical examination, and laboratory testing (eg, WBC count, erythrocyte sedimentation rate, C-reactive protein levels)
- Joint aspiration with synovial fluid analysis and culture is essential for the diagnosis
- Infection within joint space; typically bacterial
Treatment Goals
- Relieve pain
- Prevent progression
- Accommodate existing deformity
- Improve function
- Restore articular anatomy (requires surgical correction)
Disposition
Recommendations for specialist referral
- Refer to specialist (eg, orthopedist, podiatrist) for possible surgical intervention when conservative measures fail
Treatment Options
Treatment consists of conservative (nonsurgical) and surgical measures
Conservative treatment
- Preferable as first option
- Primary therapy in juvenile hallux valgus, elderly patients, and those with severe neuropathy, vascular compromise, or other comorbidity in whom surgery is contraindicated
- Does not correct the deformity but may improve symptoms and function
- Modalities include:
- Analgesics (eg, NSAIDs)
- Footwear choice: wide toe box, soft shoe with sufficiently padded insole, avoidance of high heels
- Physical therapy
- May be useful alone for mild hallux valgus, or in addition to other conservative treatments
- Can include gait training, exercise, manual therapy, taping, and orthosis
- Activity modification
- Orthotics (shoe inserts)
- May provide symptomatic relief in some patients
- Can include medial posting (to control pronation), metatarsal pad/bar (for transfer lesions), bunion flare, and extra-deep shoe with oblique toe box (accommodative)
- A Cochrane review found orthoses reduced foot pain after 6 months (compared with no treatment) but did not reduce foot pain after 6 or 12 months compared with surgery in patients younger than 60 years
- Toe spacers
- Wearing insole with toe separator may decrease pain intensity; not effective in improving great toe angles
Surgical
- Symptomatic patients in whom conservative therapy fails are candidates for surgical correction
- Continued pain and dysfunction (disruption of lifestyle/activities) are indications for surgical consideration
- Not recommended for cosmetic repair in asymptomatic patients owing to inherent surgical risks
- Principal contraindication is arterial occlusive disease; indistinct pedal pulses must be evaluated further
- Over 150 techniques have been described
- Diversity of surgeries partially owing to the multiple factors causing hallux valgus
- A Cochrane review concluded no technique has been shown to be superior
- Must be individualized for each patient
- Surgical success depends on choosing best procedure for individual given deformity
- Guided by careful evaluation of conventional radiographs
- Various factors considered, including hallux valgus angle, intermetatarsal angle, distal metatarsophalangeal joint congruity, and presence of arthritis
- Surgeon’s expertise and experience are factors
- Management of patient expectations is important; ability to wear desired footwear or perform high-impact activity should be tempered
- Up to 41% of patients are not able to return to desired footwear choices
- Options include various procedure categories, alone or in combination:
- Distal soft-tissue reconstruction
- First metatarsal osteotomies (distal and/or proximal)
- Proximal phalanx osteotomies
- Arthrodesis (fusion)
- Excisional arthroplasty
- Guided by careful evaluation of conventional radiographs
- Postoperative physical therapy and gait training may aid in improving function after surgery
Nondrug and supportive care
- Patient education
- Inform patients about progressive nature of disease process as well as treatment options and realistic goals
Special populations
- Juvenile (pediatric) hallux valgus
- Relatively uncommon in children
- Usually asymptomatic in pediatric population; typically comes to medical attention owing to cosmetic appearance of bunion
- Radiographs, in addition to showing underlying deformity, provide assessment of epiphyseal plates to aid in management decisions
- Treatment is typically conservative until after skeletal maturity
- Surgical correction associated with high recurrence rate and variable clinical outcomes; higher risk of overcorrection
- Delay is preferred until skeletal maturity unless significant pain and deformity interfere with daily living
- Epiphyseal injury may result in growth disturbance
- Surgical correction associated with high recurrence rate and variable clinical outcomes; higher risk of overcorrection
Complications
- Complications of hallux valgus include:
- Osteoarthritis of first metatarsophalangeal joint
- Deformation and pain in other digits forced upward resulting in hammer or claw toes
- Lateral metatarsalgia owing to pressure transfer from great toe to lateral metatarsal region
- Surgical complications include:
- Recurrence (foremost complication)
- Nonunion
- Avascular necrosis
- Hallux varus
- Transfer metatarsalgia
- Neuromas
- Hyperesthesia
- Degenerative arthritis
- Unmet patient expectations
Prognosis
- Left untreated, condition has uncertain prognosis
- Deformity and symptom progression may be rapid in some people whereas others remain asymptomatic
- After appropriate surgical intervention, 85% of patients are satisfied and have good clinical result
- 10% are less satisfied, with suboptimal outcome; 5% have poor results
- Relief of pain is primary objective, but ability to wear smaller/narrower shoes is a frequent goal
- Up to 41% of patients are unable to return to desired shoe choices
Prevention
- No prevention strategy known; cause is likely multifactorial, involving interplay between intrinsic and extrinsic factors
References
Coughlin MJ et al: Hallux valgus: demographics, etiology, and radiographic assessment. Foot Ankle Int. 28(7):759-77, 2007 Cross Reference